Cardiology Coding Alert

Reporting this ECG code for an inpatient? Check our tips first.

If you’ve got place of service 21 on a claim for 93042, you may be setting yourself up for trouble.

Here’s the scoop: NGS Medicare is performing a service-specific prepayment review for JK cardiology providers, specialty 06, in Connecticut and New York. The review focuses on claims billed with 93042 (Rhythm ECG, 1-3 leads; interpretation and report only).

Results: For January, February, and March, NGS reduced or denied 100 percent of the 93042 claims billed. You read that right: 100 percent.

Follow the tips below to be sure your claims meet requirements for this commonly misreported code, whether you’re reporting to NGS or another payer.

Tip 1: Distinguish Rhythm Strip From Telemetry

The NGS review found a lot of issues with 93042 reported with POS 21 (Inpatient hospital). Documentation showed patients were receiving telemetry monitoring instead of the billed 93042 service.

Code 93042 “is inappropriate to describe telemetry monitoring or even a physician’s review of telemetry strips. Appropriate billing of 93042 would be for EKGs with a specific order related to a specific set of symptoms or conditions,” says  Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

There is a difference between telemetry (continuous monitoring) and a rhythm strip (typically a single, limited, one lead tracing for a limited period of time), says Ray Cathey, PA, MHS, CMSCS, CHCI, president of Medical Management Dimensions in Stockton, Calif. 

You shouldn’t report telemetry separately because it is a routine inpatient service. “Telemetry interpretation has been an integral part of initial and subsequent hospital visits for many years,” Cathey explains.

CPT^® states in its instructions that “it is not appropriate to use these codes [93040-93042] for reviewing the telemetry monitor strips taken from a monitoring system,” Cathey adds.

“Frankly, billing for rhythm strip in the inpatient setting should be reserved for non-telemetry patients only and used infrequently. If a patient is having runs of ventricular (VT) or supraventricular (SVT) tachycardia or other dysrhythmias, they need to be on telemetry from a clinical monitoring standpoint,” Cathey says.

Tip 2: Confirm Order and Report for 93042

One element that can help you determine whether the cardiologist performed a 93042 service instead of a telemetry service is the nature of the documentation.

The NGS review reduced and denied many 93042 claims because of a “lack of required specific order for an electrocardiogram rhythm strip followed by a separate, signed, written, and retrievable report per the CPT^® definition.”

Order: “Reserve the 93042 code specifically for ordered rhythm strips,” Cathey says. “Don’t use it for telemetry patient interpretations.”

CPT^® guidelines state, “Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.”

Telemetry “is usually ordered on admission as a continuous monitoring, so that wouldn’t qualify as an order for a rhythm strip,” Cathey adds. 

Interpretation: Be sure the medical necessity for the ECG is clearly stated and that there is “a distinct, dated, legible interpretation, separately documented and signed,” Cathey says.

“Most providers who review telemetry don’t provide this information,” Cathey warns. He advises making the report “separate, meaning not part of a routine progress note unless there is a separate heading with interpretation.”

Warning: “Signing the report printed out by the ECG monitoring equipment is not acceptable documentation for billing and interpretation of a rhythm strip,” the NGS results state.

Bottom line: The CPT^® instructions with 93040-93042 are clear, Cathey says: “There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.”

Tip 3: Don’t Get Caught by the Small Stuff

NGS reduced and denied 93042 claims for two additional reasons:

• Lack of documentation for the billed date of service
• Illegible documentation.

A likely culprit for “Lack of documentation for the billed date of service” denials “is that the billed date of service does not match the documented date of service. This can be challenging if interpretations are performed on a different date from the date the study was performed. There needs to be clear documentation of the date that the physician did his interpretation,” Bucknam says.

To prevent “illegible documentation” denials, keep in mind that “legibility is more than just handwriting. The note must actually be comprehensible. Since the move to more and more electronic records I've seen lots of electronic notes that were so jumbled or poorly written I could not figure out what the provider was referring to. Providers need to read their documentation and be sure that it says what they actually mean to say. This is especially important if the physicians are using templates or Dragon to help create documentation,” Bucknam says.

“The other possibility related to legibility could be the provider signature. Medicare requires that signatures are legible or, if not legible, that additional documentation (e.g., signature logs) is also supplied with the clinical record in order for claims to be paid,” Bucknam says.

If illegible documentation is the issue, it may help to keep track of the number of services denied for that reason, and share the dollar amounts lost with providers so they understand the consequences.

Bonus tip: Another area “on Medicare’s radar is patients who receive tests like EKGs in the ED but the interpretation is not performed before the patient is discharged from the ED (or sometimes not even performed while the patient is still in the hospital). Medicare often considers that the services were not medically necessary for the date of service if the interpretation is not completed while the patient is still having those acute care services,” Bucknam says. You may see Medicare deny these claims because of a lack of medical necessity.